低位腹主动脉阻断技术在高位骶骨肿瘤切除重建的研究

The Preliminary Study of AAC in Surgical Reconstruction of High Sacral Tumor

目的探讨低位腹主动脉阻断技术在高位骶骨肿瘤切除重建手术中的应用.方法收集2003年8月至2010年3月间17例高位骶骨肿瘤切除重建手术治疗病例,男性9例,女性8例,中位年龄42岁.病理诊断:脊索瘤2例,骨巨细胞瘤7例,转移瘤4例,动脉瘤样骨囊肿1例,骨肉瘤1例,软骨肉瘤2例.手术采用以低位腹主动脉阻断技术为主的综合手段控制术区出血,TSRH/ISOLA重建腰骶椎结构.分别于阻断前5min、阻断后5 min、开放前5 min、开放后5 min及术毕记录心率、血压,同时观察和记录术中出血量、输血量、输液量及尿量.记录患者术前和术后72 h凝血功能、肾功能指标变化.分别于术后24 h、48 h、72 h随访患者肢体功能情况及其他相关并发症.结果全部手术成功,无1例术中死亡;2例术后局部复发,其中1例术后17个月复发,另1例术后23个月复发,前者改用放疗,后者再次手术治疗;1例于术后9个月因内固定本松动再次手术取出内固定.平均随访41个月.本组17例,手术时间(258±143)min,低位腹主动脉阻断时间(50±11)min,最短30 min,最长64 min.术中失血量1 600～7 500 mL,平均失血量3 100 mL.平均输血量3 326 mL.平均尿量816 mL.术中激活全血凝固时间(ACT)(204±12.44)s,术毕鱼精蛋白拮抗后ACT(118±14.61)s.手术前后凝血功能、肾功能指标差异无统计学意义.阻断前5 min、阻断后5 min,开放前5min和术毕各时点之间心率、血压差异无统计学意义(P>0.05);开放后5 min与开放前5 min相比,心率明显增快(P<0.05);开放后5 min与阻断后5 min相比,血压明显下降(P<0.05),收缩压、舒张压分别下降19%、13%,但心率、血压变化均在临床正常范围.结论低位腹主动脉阻断技术在高位骶骨肿瘤切除重建手术中的应用有助于手术的安全性,临床应用中应该严格把握适应症.TSRH/ISOLA的固定效果肯定,具有良好的机械和生物学优势.

Objective To investigate the application of the abdominal aorta clamping（AAC）in surgical reconstruction of high sacral tumors.Methods We collected 17 cases of high post sacral tumor surgically treated form August 2003 to March 2010,including 9 male and 8 female patients with the median age 42 years old.In the patients,there were 2 cases of chordoma,7 cases of giant cell tumor of bone,4 cases of metastatic tumor,1 case of aneurysm bone cyst,1 case of osteosarcoma and 2 cases of chondrosarcoma.AAS was used to control bleeding during surgery.TSRH/ISOLA was used to reconstruct the structure of sacrum and lumber.We recorded respectively the heart rate and blood pressure 5 minutes before the block,5 minutes after the block,5 minutes before lifting the block,5 minutes after the lifting of block and after surgery,in the same time we observed and recorded the amount of bleeding,transfusion,infusion and urine.We also recorded the changes of blood coagulation and renal function related indices before and 72 hours after surgery.Limbs function and related complications were also recorded in 24,48,72 hours after surgery.Results All patients got successful surgery,and there was no death case.The local recurrence was found in two patients,one patient recurred in the 17th month after surgery,and another patient recurred in the 23rd month after surgery.The former patient were give radiotherapy,and the latter patient received the second surgery.One patient had to take out the internal fixation in the 9th month after the operation.The average follow-up period was 41 months.The operative time was 258±143 min,the AAS time was 50±11 min,the shortest AAS time was 30 min and the longest was 64 min.The intraoperative blood loss was 1600～7500 mL,the mean intraoperative blood loss was 3100 mL,the mean blood transfusion was 3326 mL,the mean urinary out put was 816 mL,the ACT was 204±12.44 s,the antagonism effects of protamine after surgery leaded to ACT reduced to 118±14.61 s.The preoperative and postoperative congulant function and renal function had no significant difference.At the time 5 minutes before and after aortic block and 5minutes before clearing aortic block and the end of surgery,HR and BP had no significant difference.Compared with 5 minutes before clearing aortic block,the heart rate at the 5 minutes after clearing aortic block was significantly increased（P0.05）.Compared with 5 minutes after aortic block,the BP 5 minutes after clearing aortic block was significantly decreased（P0.05）,the systolic pressure and diastolic pressure were decreased by 19% and 13%,respectively,but the changes of heart rate and BP were considered clinically acceptable.Conclusions AAC is good and safe for high post sacral tumor surgical treatment.The indications of AAC should be recognized carefully.The TSRH/TSOLA has exact fixing effect,and has good mechanical and biological advantages.